Appealing a Denied Claim
Formal Grievance Review
Blue Cross and Blue Shield will let you know that your request was received by sending you a written confirmation within 15 calendar days.
Or, you may send your grievance to Blue Cross and Blue Shield’s Grievance Program internet address at email@example.com. Blue Cross and Blue Shield will let you know that your request was received by sending you a confirmation immediately by e mail.
Or, you may call Blue Cross and Blue Shield’s Grievance Program at 1-800-462-5601 (extension 63605). When your request is made by telephone, Blue Cross and Blue Shield will send you a written account of the grievance within 48 hours of your phone call.
Once your request is received, Blue Cross and Blue Shield will research the case in detail, ask for more information as needed and let you know in writing of the decision or the outcome of the review. If your grievance is regarding termination of coverage for concurrent services that were previously approved by Blue Cross and Blue Shield, the disputed coverage will continue until this grievance review process is completed. This continuation of coverage does not apply to services that are limited by dollar or visit maximums and that exceed those maximums, non covered services or services that were received prior to the time that you requested a formal grievance review, or when a grievance is not received on a timely basis, based on the course of treatment.
All grievances must be received by Blue Cross and Blue Shield within one year of the date of treatment, event or circumstance, such as the date you were told of the service denial or claim denial.
What to Include in a Grievance Review Request
Your request for a formal grievance review should include: the name and identification number of the member asking for the review; a description of the problem; all relevant dates; names of health care providers or administrative staff involved; and details of the attempt that has been made to resolve the problem. If Blue Cross and Blue Shield needs to review the medical/dental records and treatment information that relate to your grievance, Blue Cross and Blue Shield will promptly send you an authorization form to sign if needed. You must return this signed form to Blue Cross and Blue Shield. It will allow for the release of your medical/dental records. You also have the right to look at and get copies (free of charge) of records and criteria that Blue Cross and Blue Shield has and that are relevant to your grievance, including the identity of any experts who were consulted.
You may choose to have another person act on your behalf during the grievance review process. You must designate this person in writing to Blue Cross and Blue Shield. Or, if you are not able to do this, a person such as a conservator, a person with power of attorney or a family member may be your authorized representative. Or, he or she may appoint another party to be the authorized representative. (When you are an inpatient, a health care provider may act as your authorized representative to ask for an expedited grievance review. You do not have to designate the health care provider in writing.)
Who Handles the Grievance Review
All grievances are reviewed by individuals who are knowledgeable about Blue Cross and Blue Shield and the issues involved in the grievance. The individuals who will review your grievance will be those who did not participate in any of Blue Cross and Blue Shield’s prior decisions regarding the subject of your grievance, nor do they work for anyone who did. When a grievance is related to a necessity and appropriateness denial, at least one grievance reviewer is an individual who is an actively practicing health care professional in the same or similar specialty that usually treats the medical/dental condition, performs the procedure or provides treatment that is the subject of your grievance.
The review and response for Blue Cross and Blue Shield’s formal grievance review will be completed within 30 calendar days. Every reasonable effort will be made to speed up the review of grievances that involve health care services that are soon to be obtained by the member. (When the grievance review is for services you have already obtained and it requires a review of your medical/dental records, the 30 day response time will not include the days from when Blue Cross and Blue Shield sends you the authorization form to sign until it receives your signed authorization form if needed. If Blue Cross and Blue Shield does not receive your authorization within 30 calendar days after you are asked for it, Blue Cross and Blue Shield may make a final decision about your grievance without that medical/dental information.)
Note: If your grievance review began after an inquiry, the 30-day response time will begin on the day you tell Blue Cross and Blue Shield that you disagree with Blue Cross and Blue Shield’s answer and would like a formal grievance review.
Blue Cross and Blue Shield may extend the time frame to complete a grievance review, with your permission, in cases when Blue Cross and Blue Shield and the member agree that additional time is required to fully investigate and respond to the grievance. A grievance that is not acted upon within the specified time frames will be considered resolved in favor of the member.
Once the grievance review is completed, Blue Cross and Blue Shield will let you know in writing of the decision or the outcome of the review. If Blue Cross and Blue Shield continues to deny coverage for all or part of a health care service or supply, Blue Cross and Blue Shield’s response will explain the reasons. It will give you the specific medical and scientific reasons for the denial and a description of alternative treatment, health care services and supplies that would be covered.
Blue Cross and Blue Shield will maintain a record of all formal grievances, including the response for each grievance review, for up to seven years.
Expedited Review for Immediate or Urgently-Needed Services
In place of the formal grievance review described above, you have the right to request an “expedited” review right away when your situation is for immediate or urgently-needed services. Blue Cross and Blue Shield will review and respond to grievances for immediate or urgently-needed services as follows:
When your grievance review concerns medical care or treatment for which waiting for a response under the grievance review timeframes described above would seriously jeopardize your life or health or your ability to regain maximum function as determined by Blue Cross and Blue Shield or your physician, or if your physician says that you will have severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance review, Blue Cross and Blue Shield will review your grievance and notify you of the decision within 72 hours after your request is received.
When a grievance review is requested while the member is an inpatient, Blue Cross and Blue Shield will complete the review and make a decision regarding the request before the patient is discharged from that inpatient stay. Coverage for those services in dispute will continue until this review is completed.
A decision to deny payment for health care services may be reversed within 48 hours if the member’s attending physician certifies that a denial for those health care services would create a substantial risk of serious harm to the member if the member were to wait for the outcome of the normal grievance process.
A grievance review requested by a member with a terminal illness will be completed within five working days of receiving the request. In this case, if the expedited review results in a denial for health care services or treatment, Blue Cross and Blue Shield will send a letter to the member within five working days that explains the specific medical and scientific reasons for the denial and a description of alternative treatment, health care services and supplies that would be covered and information about requesting a hearing. When the member requests a hearing, the hearing will be held within ten days (or within five working days if the attending physician determines after consultation with Blue Cross and Blue Shield’s Medical Director and based on standard medical practice that the effectiveness of the health care service, supply or treatment would be materially reduced if it were not furnished at the earliest possible date). You and/or your authorized representative(s) may attend this hearing.